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Mary Wood, BSc PT
This WellSpring article discusses a common and often forgotten physical activity barrier of reduced bladder control, arising from pelvic floor dysfunction or pelvic health issues. The author provides suggestions and insights to health practitioners about the importance of promoting pelvic health, particularly pelvic floor muscle training.
It’s helpful to remind ourselves, as practitioners and professionals, of the importance of good pelvic health, and to acknowledge that many people experience pelvic health dysfunction which can impede their willingness or ability to be physically active.
Having a pelvic floor issue, such as bladder leakage, frequency and urgency, is the third-most common chronic complaint in the U.S. (Bump & Norton, 1998). Unfortunately, this reality does not get the attention it deserves, partly because it is unlikely anyone will die from leakage, and perhaps more commonly, because there are significant societal “taboos” around discussing bladder and bowel function.
The Coyne multinational study (15,000 women and 10,000 men) confirms the prevalence of leakage symptoms and exposes the negative impact on mental health and health-related quality of life (Coyne et al., 2012). There are few specific studies on the impact of such symptoms on physical activity.
Bladder leakage, frequency and urgency are health issues commonly experienced by men and women. For women, bladder-related symptoms can occur throughout the lifespan:
In childhood, girls have a higher tendency to develop urinary tract infections.
During childbearing years, pregnancy-related bladder leakage is >50% in the third trimester and following labour/delivery trauma.
Menopause can be another time when pelvic floor dysfunction emerges, e.g., frequency, urgency and prolapse symptoms. Such symptoms may be the primary barrier to activity.
Pelvic organ prolapse (i.e., abnormal laxity of supportive fascia and descent of pelvic contents) can compound the impact of bladder leakage and be a further barrier to activity.
Other chronic medical conditions, such as fibromyalgia or osteoporosis, have comorbid bladder symptoms, which can negatively impact management of those conditions.
Women and girls who do jumping sports (e.g., trampoline or CrossFit) have reported experiencing stress incontinence/leakage (Da Roza, 2014).
For men, bladder symptoms may occur at different stages of life. For instance, young boys may experience bladder symptoms associated with bedwetting. Generally, after the age of 50, bladder-related symptoms may be just one of many conditions or factors affecting physical activity.
Pelvic Floor Muscle Training
There are many ways for a practitioner to help a person who is experiencing a pelvic health issue. For starters, a practitioner can help a client by acknowledging the person’s symptoms, offering encouragement, and noting that practical exercises and lifestyle modifications can have a positive impact.
Pelvic floor muscle training (PFMT) can be an effective way to help treat people who experience reduced bladder control or other pelvic health issues.
It’s important to note that PFMT is more than just “Kegels”. Kegels were named for a particular type of pelvic floor exercise which focused on strong holds (contracting of pelvic muscles) and are often recommended for women after childbirth.
Proper PFMT requires much more than just strong contractions. PFMT includes a variety of specific pelvic floor muscle exercises (e.g., strong core engagement, downtraining, the “lock”, quick flick/speed, and endurance) and dynamic pelvic floor muscle exercises. Dynamic pelvic floor muscle exercises (PFMEs) are general body exercises that have been shown to have positive impacts on the pelvic floor, such as hypopressive training, Pilates, and mula bandha in yoga. PFMT has been accepted as the first line of treatment for all types of pelvic floor disorders.
Recently, a Cochrane systematic review (Dumoulin, Hay-Smith, & Mac Habée-Séguin, 2014) indicated that evidence supporting the value of PFMT is not as strong as some other individual studies would suggest. One issue is the heterogeneity of different studies, e.g., population, method, or PFMT program factors. In addition, the use of variable incontinence symptoms, e.g., Urge Urinary incontinence, Nocturia, or Mixed Urinary incontinence, can make it more difficult to assess such studies overall. These factors do not suggest PFMT is not important, but do suggest that more research on non-pharmacological aspects is required.
How Can Practitioners Help?
Unfortunately, the majority of people affected by a pelvic health issue or bladder dysfunction (e.g., reduced control) do not seek medical help until the problem is severe.
Health care practitioners and fitness professionals can play a role in promoting good pelvic health and helping to dispel myths about pelvic health symptoms.
Here are some suggestions:
1) Ask specific questions when doing an intake or taking a general history.
Many people think bladder symptoms are “normal”. They may not consider that they have a pelvic health problem, so specific questions are necessary, such as:
- Do you leak when you cough, sneeze or do an activity?
- Do you void more than eight times during the day or more than once overnight?
- Do you have urgency to void? Or, is urgency increased or triggered by events or actions, such as hearing the sound of running water, struggling to get a key in a lock, or as you approach closer to a toilet or washroom facility?
- Do you have feelings of heaviness/pressure in your bottom?
- Does leakage or urgency stop you from doing your chosen sports or physical activities?
2) Explain how PFMT and lifestyle changes can significantly improve and sometimes “cure” bladder leakage and other pelvic conditions.
3) Refer clients to programs that have appropriate knowledge about pelvic health conditions.
4) Advise clients/patients to use appropriate incontinence pads There are many good products/brands available, yet many people are still using either menstrual pads or the incorrect incontinence pads. (There are also anal tampons available for those with fecal incontinence.)
5) If you are a healthcare provider:
a) Those that do pelvic internal examinations can screen for pelvic floor muscle ability.
b) Coccygeal mobility testing (external palpation) has been shown to be an accurate screening test when carried out by trained professionals.
c) Encourage good bladder habits:
- voiding patterns—goal is to go every 2 hours and not wait longer than 4 hours;
- sit on toilet (avoid perch and hover) and avoid pushing for voiding;
- if you MUST perch or hover, consider “help” from devices like She Wee or You Go Girl (available at outdoor outfitters);
- drink 8–10 glasses of fluid per day (non-caffeinated).
d) Encourage good bowel routines:
- manage chronic constipation;
- have bowel movement before sport/training.
e) Explore the impact of possible irritants, e.g., caffeine or aspartame.
f) Refer to family physician.
g) Refer to a pelvic health physiotherapist:
- contact www.physiotherapyalberta.ca—click on “Find a physiotherapist” and look under women’s health, or urology;
- contact [email protected] for a list of providers in northern and central Alberta, including their areas of interest.
About the Author
Mary Wood is the Clinic Director at CURA Physical Therapies in Edmonton. The clinic provides both traditional and musculoskeletal physiotherapy and offers the biggest community-based pelvic health physiotherapy program in Alberta. Mary has included pelvic health physiotherapy in her active practice for over 20 years. She has also presented or led numerous lectures and workshops for public and healthcare professionals.
Bump, R. C., & Norton, P. A. (1998). Epidemiology and natural history of pelvic floor dysfunction. Obstetrics and Gynecology Clinics of North America, 25, 723-746.
Coyne, K. S., Kvasz, M., Ireland, A. M., Milsom, I., Kopp, Z. S., & Chapple, C. R. (2012). Urinary incontinence and its relationship to mental health and health-related quality of life in men and women in Sweden, the United Kingdom and the United States. European Urology, 61, 88-95. doi:10.1016/j.eururo.2011.07.049
Da Roza, T., Brandão, S., Mascarenhas, T., Jorge, R. N., & Duarte, J. A. (2014). Volume of Training and the Ranking Level are Associated with the Leakage of Urine in Young Female Trampolinists. Clinical Journal of Sports Medicine, July 9, 2014 [EPub ahead of print]. doi:10.1097/JSM.0000000000000129
Dumoulin, C., Hay-Smith, E. J. C., & Mac Habée-Séguin, G. (2014). Pelvic floor muscle training versus no treatment, or inactive control treatments, for urinary incontinence in women. Cochrane Database of Systematic Reviews, Issue 5, Article No. CD005654. doi:10.1002/14651858.CD005654.pub3
Since January 2013, each issue of WellSpring includes a short message from Alberta's Associate Minister of Wellness, the Honourable Dave Rodney.
Invitation for Albertans to Get Engaged in Wellness
Our government is committed to helping Albertans to be well in body, mind, and spirit—over the course of their entire lives. With a multitude of stakeholders, we developed “Alberta’s Strategic Approach to Wellness”, to set the stage for making that happen. The strategy defines wellness as something we build together with our families, schools, communities and workplaces, in our parks and playgrounds, the places we live, the air we breathe, and the choices we make. This framework is ground-breaking: it goes beyond suggesting that Albertans eat healthy and get active; it encourages the collaboration of a legion of partners, communities, schools, businesses, and sectors.
We need people to work together in new and different ways if we want to achieve the goals for wellness that matter to all of us. That’s why we recently launched the “Let’s Talk about Wellness” webpage, which serves as a precursor for the province-wide conversation that all Albertans will be encouraged to join later this fall—when Albertans will have an opportunity to join together and share their ideas and priorities online and through community conversations. Albertans can visit www.talkwellness.ca to learn more about the conversation and express their interest in taking part.
I hope that you will go online to share your ideas and talk about how we can promote wellness, while transforming our attitudes and actions—to improve the health and the quality of life of all Albertans!
Honourable Dave Rodney (BA, BEd, MRE), MLA Calgary-Lougheed, has been a wellness champion during his three Legislative terms—during which he has served on over 2 dozen committees. He is an entrepreneur, filmmaker, writer, keynote speaker, educator, and is the first Canadian to summit Mt. Everest two times. He founded the “Top of the World Society for Children” with his wife Jennifer; and they have two wonderful sons.